A recent New York Times article described a harrowing situation faced by some people who inject drugs and develop endocarditis, a life-threatening infection caused by bacteria that enter the bloodstream and settle in the heart. The article described doctors in Tennessee deciding whether to perform repeat costly heart surgeries on patients who were re-infected with endocarditis as a result of ongoing illicit drug use—and at times declining to operate. This scenario is not unique to Tennessee. National Public Radio tracked similar cases in Massachusetts last year, noting that providers around the country are dealing with the same dilemma. A 2017 Health Affairsstudy found that severe infections such as these have been soaring in line with the opioid epidemic.
Physicians making a choice about whether to operate is arguably a reflection of how the health care system continues to treat people with a substance use disorder as less deserving of care and treatment than people with other chronic diseases. If doctors—inspired by the desire to motivate patients—were to deny life-saving treatment to diabetes patients unable to control their blood sugar, they likely would be met with widespread outrage by the public. While the individual providers profiled in the Times piece want to help their patients survive and maintain recovery from drug abuse, the patients appear to perceive a system that conveys distaste at best, and hostility at worst, to those suffering the acute ill effects of injection drug use.
However, the deeper failures here are not at the clinical level: They are failures of policy. The scenario described by the Times reflects the results of three significant policy gaps: states’ failure to expand Medicaid, insufficient support for needle exchange programs, and an inadequate number of evidence-based substance use treatment programs.